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Breast Cancer Res Treat. Author manuscript; available in PMC 2014 April 01.
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Breast Cancer Res Treat. 2013 April ; 138(3): 719–726. doi:10.1007/s10549-013-2493-2.
Invasive ductal carcinoma with lobular features: a comparison

study to invasive ductal and invasive lobular carcinomas of the
breast
David P. Arps,
Department of Pathology, University of Michigan Health System, 1500 E. Medical Center Dr.,
2G340, Ann Arbor, MI 48109, USA
Patrick Healy,
Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
Lili Zhao,
Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
Celina G. Kleer, and

Judy C. Pang
Abstract
Invasive ductal carcinoma with lobular features (IDC-L) is not recognized as a distinct subtype of
breast cancer, and its clinicopathologic features and outcomes are unknown. In this retrospective
study, we focused on characterization of clinicopathologic features and outcomes of IDC-L and
compared them to invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC). 183
cases of IDC-L from 1996 to 2011 were compared with 1,499 cases of IDC and 375 cases of ILC.
Available slides of IDC-L (n = 150) were reviewed to quantify the lobular component (≤20, 21–
50, 51–80, >80 %), defined as small cells individually dispersed, arranged in linear cords, or in
loose aggregates without the formation of tubules or cohesive nests. E-cadherin immunostain was
performed to confirm ductal origin. Compared to IDC, IDC-L was more likely to have lower
histologic grade (p < 0.001), be positive for estrogen receptor (96 vs. 70 %; p < 0.0001) and
progesterone receptor (84 vs. 57 %; p < 0.0001), and less likely to overexpress HER-2/neu (12 vs.
23 %; p = 0.001). Despite these favorable prognostic features, IDC-L had a higher frequency of
nodal metastases (51 vs. 34 %; p < 0.0001) and a worse 5-year disease-free survival than IDC
(hazard ratio = 0.454; p = 0.0004). ILC and IDC-L had similar clinicopathologic features and
outcomes. The proportion of the lobular component in IDC-L had no impact on the size, nodal
status, stage, or outcome. Our data suggest that although IDC-L may be a variant of IDC, with >90
% of cases being E-cadherin positive, the clinical and biological characteristics are more similar to
that of ILC.
© Springer Science+Business Media New York 2013

J. C. Pang jcpang@med.umich.edu.
Conflict of interest The authors have no disclosures or conflict of interest.
Arps et al. Page 2
Keywords
Breast; Carcinoma; Ductal; Lobular
Introduction
Breast cancer is a heterogeneous group of tumors with variable morphology, behavior,
response to therapy, and molecular profiles. Invasive ductal carcinoma (IDC) is the most
common histologic type comprising 72–80 % of all invasive breast cancers, while invasive
lobular carcinoma (ILC) is less common and accounts for 5–15 % of all invasive breast
cancers [1–5]. The clinical and biological characteristics of both IDC and ILC have been
well described in the literature [1–9]. ILC differs from IDC in risk factors, histologic
features, immunophenotype, molecular profiles, and response to systemic therapy [3]. ILC is
more frequently hormone receptor positive, demonstrate a higher incidence of synchronous,
contralateral primary tumors, present more frequently with multi-centric disease, and
metastasize to distinct sites such as meninges, serosa, and retroperitoneum [10–13]. Studies
comparing survival of ILC and IDC have provided variable results. Although some studies
have shown poorer responses to therapy for ILC and higher tumor recurrence, others have
shown improved survival [14, 15].
Invasive ductal carcinomas with lobular features (IDC-L) are commonly observed in daily
pathology practice. Despite their frequency, there are no defined criteria or uniform
terminology for their diagnosis. It is a category used when there is the presence of a mixture
of ductal cytology and growth pattern (pleomorphic cells with cohesive cellular arrangement
with or without lumen formation) and lobular pattern (dispersed infiltrating fashion) in the
same lesion, or occasional tubules or small nest formation in a lesion that otherwise shows a
typical lobular type of infiltration and cytology [16]. In routine practice, many of these
tumors are diagnosed as mixed ductal and lobular carcinomas, mammary carcinoma with
ductal and lobular features, IDC-L, or simply as ductal or lobular carcinoma. The world
health organization (WHO) definition of a mixed ductal and lobular carcinoma is a tumor in
which the lobular component comprises at least 50 % of the tumor. E-cadherin expression is
typically lost in the lobular component in these cases [16]. In contrast, variable staining for
E-cadherin in IDC-L has been reported, but a majority of cases are E-cadherin positive
supporting a ductal origin [16]. We will hereinafter refer to mixed ductal and lobular
carcinomas, as defined by the WHO, as mixed tumors.
Comprehensive studies of IDC-L are lacking in the literature, and it is unclear whether this
subtype is a variant of IDC or a true mixed ductal and lobular carcinoma by WHO criteria.
The aim of this current study was to perform a retrospective analysis of a large cohort of
patients treated at our institution, focusing on morphology and on characterization of the
clinicopathologic features and outcomes of IDC-L to determine if these are true mixed
tumors or a variant of ductal carcinoma that may need to be distinguished from invasive
ductal and invasive lobular carcinoma.
Materials and methods

Study population
This study was approved by the Institutional Review Board at University of Michigan.
Using the keywords “invasive ductal carcinoma with lobular features”, “mammary
carcinoma with ductal and lobular features”, and “mixed ductal and lobular carcinoma”, 332
patients with IDC-L were identified from the University of Michigan (UMHS) pathology
database from 1996 to 2011. Only patients who received primary surgical or medical
Arps et al. Page 3
treatment at UMHS were included in the study (n = 183). 1,499 patients with IDC, not
otherwise specified, and 375 patients with ILC from the UMHS breast cancer tumor registry
from 1996 to 2007 were used as the comparison groups. All patients with the diagnosis of
ILC from the registry were included during this time period. For patients with IDC, those
with special histologic types (tubular, mucinous, and medullary) were excluded and only
those with hormone receptor and HER-2/neu status readily obtainable from the database
were included. The clinical and biological behavior of this random selection of IDC patients
appeared to be representative of this type of breast cancer reported in the literature [3, 17,
18].
Clinical and pathologic data including age, histologic type, tumor size, lymph node status,
ER, PR, and HER-2/neu status, vital status, and treatment were obtained from the breast
cancer tumor registry database, with search of the medical records to obtain missing
information. The lymph node assessment protocol at UMHS is with hematoxylin and eosin
sections.
Microscopic review
Available slides of IDC-L (150 cases) were reviewed by two pathologists to quantify the
lobular component, defined as small cells individually dispersed, arranged in linear cords, or
in loose aggregates without the formation of tubules or cohesive nests (see Fig. 1a, b). Semi-
quantification of the proportion of the lobular component was grouped as ≤20, 21–50, 51–
80, >80 %. Immunostains for E-cadherin (Clone HECD-1, Zymed) following the
manufacturer’s protocol were performed to confirm ductal origin on cases with available
tissue blocks (126 cases) (see Fig. 1c).
Statistical methods
Categorical prognostic factors were analyzed using Chi square test or Fisher exact test.
ANOVA was used to compare groups with continuous prognostic factors. Prognostic factors
included age, size, nodal status, hormone receptor, and HER-2/neu expression, and
histologic grade. Disease-specific survival was defined as from date of diagnosis to death
with disease. Patients who were alive or died of other causes without disease at the time of
death were censored at the time of last follow-up. Disease-free survival was defined from
date of diagnosis to disease progression or death. Data were censored at the last follow-up
for patients who were disease-free at the time of analysis. Survival functions were estimated
using Kaplan–Meier methods. Differences in survival functions were assessed using Cox’s
proportional hazards regression. Multivariate Cox regression was also performed to model
survival as a function of the histology, after adjusting for size, lymph node status, ER status,
and age. Histologic grade was not included in the survival analyses because this information
was not available in many of the cases. Survival studies were conducted for a follow-up time
of 5 years. All analyses were done using SAS 9.3 software. p < 0.05 was considered as
significant.
Results
Patient and tumor characteristics
Table 1 summarizes the clinical and biological tumor characteristics of the three histologic
types of breast cancers. Patients with IDC-L presented at a mean age similar to IDC.
Compared to IDC, IDC-L were more likely to have lower histologic grade (p < 0.001), be
positive for ER (96 vs. 70 %; p < 0.0001) and PR (84 vs. 57 %; p < 0.0001), and less likely
to overexpress HER-2/neu (12 vs. 23 %; p = 0.001). Despite having these good prognostic
features, there was a higher frequency of nodal metastases (51 vs. 34 %; p < 0.0001).
Although IDC-L tumors were larger than IDC tumors, even after correcting for size, the
Arps et al. Page 4
higher frequency of nodal metastases remained significant (p < 0.05). Patients with IDC-L
presented at a slightly younger age than ILC (mean 56 vs. 58 years; p = 0.036). Compared to
ILC, IDC-L tended to have higher histologic grade (p = 0.003) and was more likely to be PR
positive (84 vs. 74 %, p = 0.01). There were no significant differences in ER and HER-2/neu
expression, tumor size, or frequency of nodal metastases between IDC-L and ILC. Although
not statistically significant, patients with IDC-L and ILC were more likely to present with
stage III disease (17 and 22 %) than patients with IDC (13 %).
A comparison between four groups of patients with different proportions of the lobular
component (≤20, 21–50, 51–80, and >80 %) did not show any statistically significant
differences with respect to the mean age, size, lymph node status, stage at presentation, ER
status, or outcome (recurrence and survival rates) (Table 2). E-cadherin immunostain
demonstrated moderate to strong membrane staining in both the ductal and lobular
components in 116 of 126 (92 %) cases confirming ductal origin. The remaining 10 cases
showed weak to absent membrane staining in both components.
Treatment
Of the 183 patients with IDC-L, for the first surgical procedure, 59 patients (32 %) had a
mastectomy and 122 (67 %) patients had a lumpectomy. Two patients did not have surgery.
Of those that had a lumpectomy as their first surgery, 60 (49 %) required additional surgery
to obtain adequate margins.
Of the 183 patients with IDC-L, 110 patients (60 %) received chemotherapy, 147 patients
(80 %) received endocrine therapy (tamoxifen and/or aromatase inhibitor), and 14 patients
(8 %) received Herceptin. Adjuvant chemotherapy, endocrine therapy, and Herceptin were
unknown for 7, 13, and 6 patients, respectively. 128 patients (70 %) received radiation after
surgery. Radiation therapy was unknown for ten patients.
Disease-free and disease-specific survival

There were no significant differences in local, regional, and distant recurrence rates between
patients with IDC and IDC-L and ILC and IDC-L (see Table 3). Distant metastases, both at
diagnosis and/or recurrences, were seen in 16 % (29 of 183) of patients with IDC-L. The
most frequent sites were bone (76 %, 22/29) and liver (45 %; 13/29). Other sites of
metastases, in order of decreasing frequency, were brain, distant lymph nodes (neck,
mediastinal, abdominal), lung, adrenal, skin, renal, peritoneum, and pericardium. 11 of 183
(6 %) patients with IDC-L had contralateral breast cancers—seven with invasive carcinoma
and four with ductal carcinoma in situ (DCIS). Contralateral breast cancers are reported to
be seen in 4.4–20.9 % of patients with ILC and 3–11.2 % of patients with IDC [3, 18, 19].
Data was available for 2,051 patients (183 IDC-L, 1,494 IDC, and 374 ILC) in the survival
analysis. The median follow-up time was 5 years (range 0.024–5 years). Univariate analysis
indicated that disease-free survival (DFS) was significantly better for IDC patients when
compared to IDC-L, however, no statistical difference was found between ILC and IDC-L.
(see Table 4; Fig. 2a). There were no significant differences in disease-specific survival
(DSS) between the histologic subtypes (see Table 4; Fig. 2b). In the multivariate analysis,
we found that size, lymph node status, and ER status were important prognostic factors
associated with DFS and DSS for IDC-L, but age was not. After adjusting for these factors,
DFS for the IDC histologic subtype remained significantly better than IDC-L (see Table 4).
There were still no differences in DSS between the histologic subtypes.
Arps et al. Page 5
Discussion
The management of breast cancer has evolved over the years with multimodality therapy
becoming commonplace. These recent advances in breast cancer treatment have required
better characterization of the different prognostic and histologic subgroups. Targeted
systemic therapy is a goal and better understanding of these differences is essential to direct
and individualize treatment decisions. IDC and ILC are the most common histologic types
of invasive breast cancers. Several molecular profiling studies, clinical data, and patterns of
metastases suggest that these histologic types of breast cancer demonstrate genetic and
biological differences. Some breast tumors contain a combination of ductal and lobular
morphologies. If such tumors contain 50 % or greater lobular morphology, they may be
classified as mixed ductal and lobular carcinoma, or mixed tumors, as defined by the WHO.
The clinical and biological significance of mixed tumors is not well characterized [1, 18,
20], however, studies suggest that they may behave different clinically as compared to IDC.
The frequency of lymph node metastasis for mixed tumors has been reported to range from
26 [21] to 41 % [22]. In one study, no clinically meaningful difference was seen in survival
between IDC and mixed tumors [22]. However, in a different study [23], patients with
mixed tumors presented with more advanced disease but had survival superior to patients
with IDC, similar to ILC. No published studies, to our knowledge have specifically
addressed the behavior of invasive ductal carcinoma with lobular features.
We observed that IDC-L was associated with patient and tumor characteristics that were
more similar to ILC than with IDC. IDC-L had lower histologic grade, higher rates of
hormone receptor positivity and lower rates of HER-2/neu overexpression than IDC. Despite
these features that are typically considered to be prognostically favorable, IDC-L had a
higher rate of nodal metastasis than IDC. The presence of lobular morphology in any
proportion, similar to micropapillary morphology, may be an unfavorable histologic feature
[24]. 16 % (29/183) of patients with IDC-L had distant metastases at diagnosis and/or
recurrences. Similar to the data on mixed tumors reported by Rakha et al. [22], our data
showed frequent metastases to bone (76 %, 22/29). This propensity for metastasis to the
bone is more characteristic of ILC. Lee et al. [19] reported a bony metastasis rate of 72.7 %
in ILC and 36.5 % in IDC in patients with systemic recurrence of disease. In our study, a
majority of patients with IDC-L (67 %) had a lumpectomy as their initial surgical procedure.
Interestingly, re-excision was required in 49 % of these patients to achieve adequate
margins. The re-excision rate for positive/close margins on all breast cancers at our
institution is 25 % as reported by Sabel et al. [25]. In the study by Moore et al. [26]
comparing the re-excision rates of ILC and IDC, the re-excision rates were 51 and 15 %,
respectively. In our experience, as well as in the literature [26,27], ILCs are typically less
well defined, both grossly and radiographically, tend to have more infiltrative borders, and
are more often multifocal than IDCs, making margin control more difficult. IDC-L appears
to be similar to ILC in this respect and likely accounts for the need for re-excision. Finally,
although only DFS was statistically significantly worse for IDC-L than IDC, our survival
analysis suggests that IDC-L and ILC have a trend for a worse outcome than IDC.
Diagnosing IDC-L is often subjective and the criteria for diagnosis are not well defined.
Review of the literature and experience at our institution have demonstrated that mixed
ductal and lobular carcinoma and IDC-L are not clearly defined [21–23]. At our institution,
IDC-L is used inconsistently and is often used interchangeably with mixed ductal and
lobular carcinoma and mammary carcinoma with ductal and lobular features. In the study of
mixed tumors by Rakha et al. [22], only tumors with “mixed but well defined histologic
types” were included and those with hybrid morphology that showed morphologic features
of both lobular and ductal tumors, which was described as a “lobular diffuse infiltrative
pattern but with no specific cellular morphology”, were excluded as these cases were
Arps et al. Page 6
diagnosed in their practice as IDC-L. In our study, the lobular component of the IDC-L was
defined as small cells individually dispersed, arranged in linear cords, or in loose aggregates
without the formation of tubules or cohesive nests.
The absence of E-cadherin staining is one of the major defining features of lobular tumors
and previous studies have demonstrated loss of expression in the majority of ILC (80–90 %)
and in the areas of lobular morphology in the mixed tumors, while positive in IDC and in the
ductal morphology of mixed tumors [16]. In the study by Rakha et al. [22], 70 % of the
mixed tumors had absent or reduced E-cadherin immunostaining. In a separate study by
Suryadevara et al. [21] on mixed ductal and lobular carcinoma, the histologic features were
not defined, but E-cadherin was positive in 90 % of cases. Acs et al. [16] described three
patterns of E-cadherin expression in 41 cases of IDC-L: “lobular-like” which was
characterized by a complete or almost complete loss of E-cadherin staining (10 cases, 24 %);
“ductal-like” demonstrating uniform membrane expression of E-cadherin throughout the
tumor (24 cases, 58 %); and “intermediate” where there was focally complete loss of E-
cadherin staining (7 cases, 17 %). These “intermediate” cases were subsequently reclassified
as mixed ductal and lobular carcinoma. In our current study, E-cadherin was moderately to
strongly positive in 92 % of cases (116 of 126), with immunoreactivity appreciated in both
the ductal and lobular components. 10 cases demonstrated weak to absent E-cadherin
immunostaining in both components.
To our knowledge, this is the first comprehensive study of IDC-L. Although IDC-L does not
fulfill the WHO criteria for a true mixed ductal and lobular carcinoma, it may be considered
as within the spectrum of mixed tumors as there is overlap in clinicopathologic features
reported in the literature. Limitations of this study include its retrospective nature and
potential for selection bias, as well as the short median follow-up time of 5 years. However,
important conclusions are borne from our study: (1) It may be important to distinguish
invasive ductal carcinoma with lobular features from invasive ductal carcinoma as our data
suggests that the presence of lobular morphology may be a poor prognostic feature. (2) E-
cadherin immunostain may not be necessary to determine whether the cells with lobular
morphology are lobular or ductal in origin as the clinicopathologic features and outcomes of
invasive ductal carcinoma with lobular features and invasive lobular carcinoma are similar.
Acknowledgments
The authors gratefully acknowledge the UMHS Cancer Center Research Histology & Immunoperoxidase Lab for
performing the E-cadherin immunostains and Steven C. Smith, M.D., Ph.D. for his assistance in the preparation of
Fig. 2.
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Fig. 1.
Morphology of invasive ductal carcinoma with lobular features. H&E, ×400. a Lobular
component. Malignant cells in linear cords, loose nests, and individually dispersed. b Ductal
component. Malignant cells forming tubules. c Strong immunoreactivity for E-cadherin in
the lobular component
Arps et al. Page 10
Fig. 2.
Disease-free and disease-specific survival plotted from 50 to 100 %. a Disease-free survival.
Kaplan–Meier plot of disease-free survival (DFS) of patients with IDC-L and patients with
IDC and ILC showing worse DFS for IDC-L compared to IDC, but no difference between
IDC-L and ILC. b Disease-specific survival. Kaplan–Meier plot of disease-specific survival
(DSS) of patients with IDC-L and patients with IDC and ILC showing no difference in DSS
between the groups
Arps et al. Page 11
Table 1
Patients and tumor biological characteristics by histologic type
IDC-L IDC ILC p(IDC) p(ILC)

Patients (n) 183 1,499 375
Age
Number with data 183 1,499 375
Mean 56.0 54.4 58.4 0.12 0.036
Grade
Number with data 179 1,399 262 <0.001 0.003
Grade 20.7 17.4 35.5
Grade 2 (%) 63.7 44.3 53.4
Grade 3(%) 15.6 38.4 11.1
Tumor size
Number with data 183 1,494 374 0.035 0.436
T1:<2 cm (%) 63.9 70.3 59.1
T2: 2.11–5 cm (%) 27.3 25.1 29.1
T3:>5 cm (%) 8.7 4.6 11.8
Positive lymph nodes

Number with data 181 1,365 341
Positive (%) 51.4 34.5 44.9 <0.0001 0.156
<0.0001 0.213
N1: 1–3 positive nodes 32.0 23.4 23.5
N2: 4–9 positive nodes 10.5 8.1 11.7
N3:>10 positive nodes 3.4 1.6 6.2
Estrogen receptor
Number tested 183 1,423 359
Positive (%) 95.6 70.1 93.3 <0.0001 0.28
Progesterone receptor
Positive (%) 83.6 56.5 74.1 <0.0001 0.01
HER-2/neu
Positive (%) 12.2 23.0 15.5 0.001 0.318

Stage
Number with data 180 1,420 363 0.113 0.32
I (%) 40.6 48.8 36.6
II (%) 37.8 35.3 34.4
III (%) 17.2 13.1 21.8
IV (%) 4.4 2.8 7.2
IDC-L invasive ductal carcinoma with lobular features, IDC invasive ductal carcinoma, ILC invasive lobular carcinoma
Arps et al. Page 12
Table 2
Clinical and tumor biological characteristics of IDC-L based on proportion of lobular component
% lobular component parameter ≤20 (%) 21–50 (%) 51–80 (%) >80 (%) (p value)
N 39 26 48 35
Mean age 58 60 55 52 (0.14)
Mean size (mm) 20.4 18.2 20.27 30.77 (0.05)
Nodal metastasis (%) 51.3 37.5 50 54.3 (0.62)
Stage (%) (0.38)
I 46.2 56 37.5 37.1
II 33.3 32 47.9 28.6
III 17.9 8 12.5 28.5
IV 2.6 4 2.1 5.7
ER positivity (%) 94.9 100 95.8 91.4 (0.54)
5-year recurrence rate(%) 15.4 11.5 12.5 25.7 (0.66)
5-year survival rate (%) 94.9 96.2 93.8 88.6 (0.83)
IDC-L invasive ductal carcinoma with lobular features, ER estrogen receptor

Arps et al. Page 13
Table 3
Recurrence rates of IDC-L, IDC, and ILC
IDC-L IDC ILC p (IDC) p (ILC)

Overall (%) (n) 14.8 (27) 13.9 (207) 22.2 (83) 0.74 0.04
Local (%) (n) 3.9 (7) 3.4 (48) 3.7 (14) 0.72 0.94
Regional (%) (n) 1.7 (3) 0.8 (12) 1.6 (6) 0.22 1
Distant (%) (n) 14.9 (27) 11.1 (162) 17.9 (67) 0.13 0.38
IDC-L invasive ductal carcinoma with lobular features, IDC invasive ductal carcinoma, ILC invasive lobular carcinoma
Arps et al. Page 14
Table 4
Cox regression analysis of disease-free and disease-specific survival
Predictor DFS DSS
Hazards ratio (95 % CI) Hazards ratio (95 % CI)

p value p value
Histology (unadjusted)
IDC versus IDC-L 0.609 (0.413, 0.899) 0.01 0.760 (0.438, 1.318) 0.33
ILC versus IDC-L 0.803 (0.521, 1.235) 0.32 0.856 (0.466, 1.572) 0.62
Histology (adjusted for size, nodal status, ER status, age)
IDC versus IDC-L 0.454 (0.294, 0.701) 0.0004 0.552 (0.297, 1.030) 0.06
ILC versus IDC-L 0.678 (0.429, 1.073) 0.097 0.689 (0.353, 1.346) 0.28
Prognostic factors of IDC-L
Size 1.012 (1.007, 1.017) <0.0001 1.014 (1.008, 1.019) <0.0001
Nodal status
N0 versus N3 0.231 (0.153, 0.351) <0.0001 0.144 (0.086, 0.244) <0.0001
N1 versus N3 0.321 (0.208, 0.496) <0.0001 0.238 (0.138, 0.410) <0.0001
N2 versus N3 0.604 (0.379, 0.962) 0.03 0.479 (0.267, 0.862) 0.01
ER status (neg vs. pos) 2.980 (2.198, 4.042) <0.0001 4.377 (2.934, 6.528) <0.0001
Age 1.003 (0.991, 1.014) 0.65 1.014 (0.998, 1.029) 0.08
DFS disease-free survival, DSS disease-specific survival, IDC-L invasive ductal carcinoma with lobular features, IDC invasive ductal carcinoma,
ILC invasive lobular carcinoma, ER estrogen receptor

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Breast Cancer Res Treat. 2013 April ; 138(3): 719–726. doi:10.1007/s10549-013-2493-2.

Invasive ductal carcinoma with lobular features: a comparison

Celina G. Kleer, and

© Springer Science+Business Media New York 2013

Materials and methods

Disease-free and disease-specific survival

1. Sastre-Garau X, Jouve M, Asselain B, et al. Infiltrating lobular carcinoma of the breast.

IDC-L IDC ILC p(IDC) p(ILC)

Positive lymph nodes

Positive (%) 12.2 23.0 15.5 0.001 0.318

IDC-L invasive ductal carcinoma with lobular features, ER estrogen receptor

IDC-L IDC ILC p (IDC) p (ILC)

Predictor DFS DSS

Hazards ratio (95 % CI) Hazards ratio (95 % CI)

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